Age at Diagnosis of Diabetes by Race and Ethnicity in the United States From 2011 to 2018 | Health Disparities | JAMA Internal Medicine | JAMA Network
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Table 1.  Demographic Characteristics of Adults With Self-reported Diabetes by Race and Ethnicity in the US, 2011-2018
Demographic Characteristics of Adults With Self-reported Diabetes by Race and Ethnicity in the US, 2011-2018
Table 2.  Distribution of Age at Diabetes Diagnosis by Race and Ethnicity in the United States, 2011-2018
Distribution of Age at Diabetes Diagnosis by Race and Ethnicity in the United States, 2011-2018
1.
Virani  SS, Alonso  A, Aparicio  HJ,  et al; American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee.  Heart disease and stroke statistics–2021 update: a report from the American Heart Association.   Circulation. 2021;143(8):e254-e743. doi:10.1161/CIR.0000000000000950PubMedGoogle ScholarCrossref
2.
Nanayakkara  N, Curtis  AJ, Heritier  S,  et al.  Impact of age at type 2 diabetes mellitus diagnosis on mortality and vascular complications: systematic review and meta-analyses.   Diabetologia. 2021;64(2):275-287. doi:10.1007/s00125-020-05319-w PubMedGoogle ScholarCrossref
3.
Koopman  RJ, Mainous  AG  III, Diaz  VA, Geesey  ME.  Changes in age at diagnosis of type 2 diabetes mellitus in the United States, 1988 to 2000.   Ann Fam Med. 2005;3(1):60-63. doi:10.1370/afm.214 PubMedGoogle ScholarCrossref
4.
Cheng  YJ, Kanaya  AM, Araneta  MRG,  et al.  Prevalence of diabetes by race and ethnicity in the United States, 2011-2016.   JAMA. 2019;322(24):2389-2398. doi:10.1001/jama.2019.19365 PubMedGoogle ScholarCrossref
5.
Hill-Briggs  F, Adler  NE, Berkowitz  SA,  et al.  Social determinants of health and diabetes: a scientific review.   Diabetes Care. 2020;44(1):258-279. doi:10.2337/dci20-0053 PubMedGoogle ScholarCrossref
6.
US Preventive Services Task Force. Screening for prediabetes and type 2 diabetes mellitus. March 16, 2021. Accessed March 24, 2021. https://www.uspreventiveservicestaskforce.org/uspstf/draft-recommendation/prediabetes-and-type-2-diabetes-mellitus-screening
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    Reporting data by race and ethnicity: why researchers must be considered in delivering key messages
    Jessica Harding, PhD | Emory University
    Wang et al. published findings on racial and ethnic disparities in self-reported age of diabetes diagnosis using the nationally representative National Health and Nutrition Examination Survey (NHANES) [1]. Overall, the authors report that non-Hispanic Black and Mexican American adults are diagnosed with diabetes, on average, 4 to 7 years earlier than non-Hispanic white adults. These findings have important long-term implications owing to the increased risk for mortality and vascular complications associated with younger age at diabetes diagnosis [2].

    Reasons for the observed disparities are not explored in this largely descriptive study, although the authors acknowledge they are likely
    “attributable to a combination of clinical, behavioral, and social factors.” Given this assertion, it is thus surprising that the authors conclusion instead lends itself to a solution largely at the individual without consideration of the broad context in which individual choices are made. Specifically, the authors report that “there may be benefit to initiating intensive lifestyle changes starting earlier in adulthood.”

    Though the authors declare race and ethnicity a ‘social construct’, they do little to explore this notion. For example, in Table 1 there is a clear difference in education attainment by different racial and ethnic groups, yet no attempt has been made to examine diabetes diagnosis stratified by this factor. Instead, the authors focus exclusively on race and do not offer alternative explanations for the root causes of the observed disparities between race and ethnic groups, such as poverty, inadequate access to healthcare, or structural racism.

    This messaging, coupled with an individual-level solution, can inadvertently reinforce structural racism by masking racial stereotypes within seemingly factual claims [3]. Indeed, in a dataset such as NHANES where several social determinant of health factors are routinely collected, it is, in our opinion, negligent not to explore the upstream factors that may explain these findings. In addition, concluding that ‘lifestyle changes’ among some racial subgroups may reduce disparities in age of diabetes onset shifts not only the solution to the individual, but also the blame. It is time we stop reporting our findings by race and ethnicity without careful consideration of the contextual information in which these differences arise. If we don’t, we are simply perpetuating the racialization of diabetes [3].

    References

    1. Wang MC, Shah NS, Carnethon MR, O’Brien MJ, Khan SS. Age at diagnosis of diabetes by race and ethnicity in the United States from 2011 to 2018. JAMA Internal Medicine 2021; doi:10.1001/jamainternmed.2021.4945

    2. Nanayakkara N, Curtis AJ, Heritier S, et al. Impact of age at type 2 diabetes mellitus diagnosis on mortality and vascular complications: systematic review and meta-analyses. Diabetologia. 2021; 64(2):275-287

    3. Tuchman AM. Diabetes - a history of race and disease. 2020; United States of America, Yale University Press.

    Authors: Jessica L Harding, Rachel E Patzer
    Affiliation: Department of Surgery, Emory University, Atlanta, USA

    CONFLICT OF INTEREST: None Reported
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    Research Letter
    September 7, 2021

    Age at Diagnosis of Diabetes by Race and Ethnicity in the United States From 2011 to 2018

    Author Affiliations
    • 1Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
    • 2Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
    • 3Division of General Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
    JAMA Intern Med. Published online September 7, 2021. doi:10.1001/jamainternmed.2021.4945

    The prevalence of diabetes in the US has increased substantially over the past 2 decades and is higher among non-Hispanic Black and Hispanic adults than non-Hispanic White adults.1 Earlier age at diabetes onset is associated with greater risk of cardiovascular disease and death2 and may contribute to observed racial/ethnic disparities in diabetes complications. Therefore, we compared the self-reported age at diabetes diagnosis by race/ethnicity in the US.

    Methods

    We performed a cross-sectional study pooling data from four 2-year cycles of the National Health and Nutrition Examination Survey, from January 1, 2011, to December 31, 2018. The Northwestern University institutional review board determined this study to be exempt from review and informed consent due to the use of deidentified data. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.

    Data were combined starting with the 2011-2012 survey because that was the first cycle to include self-identified Asian respondents. We included all adults (aged ≥20 years) who self-reported a history of diabetes and age at diagnosis. Self-reported race/ethnicity was assessed as a social construct to investigate health disparities. We computed the mean and median age at diagnosis of diabetes overall and by race/ethnicity, examining group differences using t tests and quantile regression, respectively. We additionally determined the proportion of adults in each racial/ethnic group with age at diagnosis of diabetes before age 40, 35, and 30 years. In the primary analysis, we excluded adults with a likely diagnosis of type 1 diabetes, defined by self-report of diagnosis before age 30 years and on insulin monotherapy.3 In a sensitivity analysis, we included all adults with self-reported diabetes. All reported statistics are weighted to be representative of the civilian noninstitutionalized US population. All analyses accounted for the complex sampling design of the National Health and Nutrition Examination Survey. Statistical analyses were conducted from February 22 to June 23, 2021, using Stata, version 15.1 (StataCorp LLC). All P values were 2-sided, and P < .05 was considered statistically significant.

    Results

    The study sample included 3022 participants (1586 men and 1436 women; 946 non-Hispanic White participants; weighted mean [SD] age, 61.1 [0.3] years) who reported diabetes, representing 22 844 326 adults (Table 1). The mean age at diabetes diagnosis overall was 49.9 years (95% CI, 49.2-50.7 years) (Table 2). Relative to non-Hispanic White adults (mean age, 51.8 years; 95% CI, 50.8-52.9 years), Mexican American and non-Hispanic Black adults reported a significantly younger mean age at diagnosis (mean age, 47.2 years; 95% CI, 46.1-48.4 years and 44.9 years; 95% CI, 43.4-46.4 years, respectively; P < .001), but non-Hispanic Asian adults did not (mean age, 50.5 years; 95% CI, 48.4-52.6 years). The weighted proportion of adults with diabetes diagnosed before age 40 years was greater among Mexican American adults (35.0%) and non-Hispanic Black adults (25.1%) compared with non-Hispanic White adults (14.4%) (P ≤ .001). In the sensitivity analysis including all adults with self-reported diabetes, a similar pattern in age at diabetes diagnosis was observed.

    Discussion

    In this cross-sectional study of a nationally representative sample of US adults from 2011-2018, the mean age at diabetes diagnosis was 4 to 7 years earlier in non-Hispanic Black and Mexican American adults than in non-Hispanic White adults. In addition, more than 25% of non-Hispanic Black and Mexican American adults with diagnosed diabetes reported diagnosis before age 40 years. The lack of observed differences between non-Hispanic White and non-Hispanic Asian adults may mask heterogeneity across different Asian subgroups.4 Additional limitations of this work include reliance on self-reported data, which are subject to recall bias and do not capture undiagnosed diabetes.

    Earlier age at diabetes diagnosis among non-Hispanic Black and Mexican American adults is attributable to a combination of clinical, behavioral, and social factors5 and may potentially contribute to observed disparities in diabetes-related microvascular and macrovascular complications and premature mortality. Accordingly, there may be benefit to initiating intensive lifestyle changes starting earlier in adulthood.6 Efforts to prevent and manage diabetes earlier in the life course may help reduce the substantial premature morbidity and mortality associated with diabetes.

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    Article Information

    Accepted for Publication: July 15, 2021.

    Published Online: September 7, 2021. doi:10.1001/jamainternmed.2021.4945

    Corresponding Author: Sadiya S. Khan, MD, MSc, Division of Cardiology, Northwestern University Feinberg School of Medicine, 680 N Lake Shore Dr, Ste 1400, Chicago, IL 60611 (s-khan-1@northwestern.edu).

    Author Contributions: Dr Khan had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: Wang, Shah, Carnethon, Khan.

    Acquisition, analysis, or interpretation of data: Wang, Shah, O'Brien.

    Drafting of the manuscript: Wang.

    Critical revision of the manuscript for important intellectual content: All authors.

    Statistical analysis: Wang.

    Administrative, technical, or material support: Shah, O’Brien.

    Supervision: Shah, O’Brien, Khan.

    Conflict of Interest Disclosures: None reported.

    Funding/Support: This study was supported by grants P30AG059988 and P30DK092939 from the National Institutes of Health (Dr Khan) and grant 19TPA34890060 from the American Heart Association (Dr Khan).

    Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

    Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

    References
    1.
    Virani  SS, Alonso  A, Aparicio  HJ,  et al; American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee.  Heart disease and stroke statistics–2021 update: a report from the American Heart Association.   Circulation. 2021;143(8):e254-e743. doi:10.1161/CIR.0000000000000950PubMedGoogle ScholarCrossref
    2.
    Nanayakkara  N, Curtis  AJ, Heritier  S,  et al.  Impact of age at type 2 diabetes mellitus diagnosis on mortality and vascular complications: systematic review and meta-analyses.   Diabetologia. 2021;64(2):275-287. doi:10.1007/s00125-020-05319-w PubMedGoogle ScholarCrossref
    3.
    Koopman  RJ, Mainous  AG  III, Diaz  VA, Geesey  ME.  Changes in age at diagnosis of type 2 diabetes mellitus in the United States, 1988 to 2000.   Ann Fam Med. 2005;3(1):60-63. doi:10.1370/afm.214 PubMedGoogle ScholarCrossref
    4.
    Cheng  YJ, Kanaya  AM, Araneta  MRG,  et al.  Prevalence of diabetes by race and ethnicity in the United States, 2011-2016.   JAMA. 2019;322(24):2389-2398. doi:10.1001/jama.2019.19365 PubMedGoogle ScholarCrossref
    5.
    Hill-Briggs  F, Adler  NE, Berkowitz  SA,  et al.  Social determinants of health and diabetes: a scientific review.   Diabetes Care. 2020;44(1):258-279. doi:10.2337/dci20-0053 PubMedGoogle ScholarCrossref
    6.
    US Preventive Services Task Force. Screening for prediabetes and type 2 diabetes mellitus. March 16, 2021. Accessed March 24, 2021. https://www.uspreventiveservicestaskforce.org/uspstf/draft-recommendation/prediabetes-and-type-2-diabetes-mellitus-screening
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